Welcome serve-you-rx.com

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1 Serve You Custom Rx Management is a national Pharmacy Benefit Manager that your organization has selected to provide a pharmacy benefit to you and your covered family members. We offer a wide array of tools and services to help maximize your pharmacy benefit and better manage your prescription drug costs through informed decision making. Use this brochure to find out... Where to fill prescriptions locally How to use our convenient Serve You DirectRx SM Mail Service Pharmacy Tips on making informed decisions about your pharmacy benefit Welcome A guide to help you make the most of your pharmacy benefit services Your Welcome Kit includes the following... New Prescription & Refill Order Form Prescription Transfer Form Allergy, Health Conditions & Medication Questionnaire Notice of Privacy Practices Questions? Serve You s in-house Member Services Representatives are available 364 days a year, and Serve You pharmacists are always available via telephone 24 hours a day to answer questions about your mail service prescriptions. Simply call or go online: serve-you-rx.com P.O. Box 26096, Milwaukee, WI serve-you-rx.com 2015 Serve You Custom Prescription Management CS0003(0715)

2 Finding a Retail Pharmacy The Serve You nationwide retail pharmacy network consists over 64,000 pharmacies, including all chain and most independent pharmacies. If you need help finding a participating pharmacy or verifying whether your current pharmacy is in the network, you can either login to the Member Portal at serve-you-rx.com or call Member Services. Using Serve You DirectRx Mail Service Pharmacy Serve You DirectRx Mail Service Pharmacy (DirectRx Mail), our fully owned and operated mail service, is a safe, convenient and often cost-effective way to fill maintenance prescriptions taken on a regular basis for chronic or long-term medical conditions including high cholesterol, high blood pressure and diabetes, just to name a few. DirectRx Mail offers: Free standard delivery of maintenance medications to your home or apartment Convenient refill options online, by phone and by mail Up to a 90-day supply of most medications 24/7 access to Serve You pharmacists regarding prescriptions filled by DirectRx Mail Secure, confidential packaging options, including tamper-evident and weather-resistant Need Help? Call Member Services Visit us online serve-you-rx.com Filling Your Prescription Using the Serve You DirectRx Mail Service Pharmacy Is Easy Ask your doctor to submit a prescription for the maximum days supply of your maintenance medications allowed by your plan, plus refills if appropriate, to Serve You DirectRx Mail Service Pharmacy (DirectRx Mail) by: 1. Phone to 2. Fax to Electronically to DirectRx Mail Submit Written Prescription for Maintenance Medications 1. Go to serve-you-rx.com. 2. Click on Members, go to Forms and download the New Prescription & Refill Order Form also found in this Welcome Kit. 3. Complete the form and mail it along with the original written prescription and the applicable copayment to: Serve You, P.O. Box 26096, Milwaukee, WI Serve You accepts Visa, MasterCard, American Express, Discover, personal checks and money orders. Transfer Your Prescriptions to DirectRx Mail Call Serve You Member Services at and give the Representative: Name and phone number of current pharmacy Prescription name and number found on medication label Number of refills remaining You can also complete and mail in the Prescription Transfer Form found in this Welcome Kit. Three Ways to Refill Your Prescription Using DirectRx Mail 1. Online: Go to serve-you-rx.com and click the EZRefillRx link. 2. By Phone: Call to use the automated EZRefillRx line, open 24 hours. Please have your prescription number and payment information available. 3. By Mail: Complete and return the New Prescription & Refill Order Form that was shipped with your previous order. You can also download this form online (see above) or use the printed copy found in this Welcome Kit. Making Informed Decisions Serve You Preferred Drug List A Preferred Drug List (PDL) is a list of prescription medications covered by your prescription drug plan. Its purpose is to help you and your doctor choose safe, effective and cost-efficient drug treatments. Using drugs on the PDL often results in lower out-of-pocket costs for you. The PDL is available in English and Spanish at serve-you-rx.com or by calling Member Services. Find the Lowest Copay What s My Copay? is one of the most popular features of Serve You s online Member Portal which allows you to: Compare the cost of using brand drugs vs. generics Compare the costs between pharmacies to find your lowest possible copay Quick Tips serve-you-rx.com Find the Serve You Preferred Drug List Click on Members Go to Preferred Drug List and select Serve You Preferred Drug List or Spanish Version Using What s My Copay? Login to the Member Portal Click on What s My Copay? in the top navigation and follow the prompts Lower-Cost Alternatives Generic drugs contain the same active ingredients as their brand-name counterparts and can be considerably less expensive. Therefore, an FDA-approved generic equivalent will be dispensed whenever possible based on availability and your doctor s approval. If you choose to have your prescription filled with a brand-name drug when a generic is available, you may be required to pay the cost difference in addition to your copayment. We recommend that you ask your doctor or pharmacist if a generic is available for your medications, as this may provide considerable cost savings for you.

3 New Prescription & Refill Order Form MemBer SErvices: Mail OR FAX completed form to: Serve You DirectRx SM Pharmacy P.O. Box Milwaukee, WI Fax Certification and Authorization: I certify that the information on this form is correct and further understand that any benefits are subject to my eligibility for and participation in the medical plan. I certify that I or my dependents for whom prescriptions are enclosed do not have primary prescription drug coverage under any other medical plan. NOTE: All communications, including mailed prescriptions, will be directed to the cardholder. A covered dependent who wishes to receive communications directly should include a request in writing with any prescription order. *For each account, all prescriptions ordered are sent in separate packages. New Prescription Orders: Complete page 1 and Patient Information section on page 2. Mail the order form along with the original prescriptions from your prescriber and full payment. Refill Orders: Complete page 1 and the Refill section on page 2. Mail or fax the form along with full payment. For additional forms, visit serve-you-rx.com. Please print Cardholder information Establish an account* (see NOTE) Employer/Health Plan Name: Member ID #: Group #: Last Name: First Name: MI: Permanent Address: City: State: Zip: Delivery Address: City: State: Zip: (If different than the permanent address) For this order only Primary Phone #: ( ) - Secondary Phone #: ( ) - Address: Method of payment Check or Money Order: (Payable to: Serve You) Total Amount Enclosed: $ To authorize payment by credit card, please provide following information: Use Credit Card On File: Last four digits of card on file: Credit Card: MasterCard VISA American Express Discover Name as it Appears on Credit Card: Billing ZIP Code: Credit Card #: Expiration Date (month/year): / Cardholder Signature: Today s Date (month/day/year): / / I authorize Serve You to maintain my credit card on file as payment method for any future charges. I understand that all prescription orders requested by me or new prescriptions provided to Serve You by my physician will automatically be processed and shipped using this card for payment. Signature: Today s Date (month/day/year): / / Page 1 Providing your address and phone number authorizes us to contact you about your account or our services. address will be used to send order tracking and shipping confirmation information.

4 New Prescription Orders Please print Patient #1 information: Self Spouse Dependent Patient #2 information: Self Spouse Dependent Patient #3 information: Self Spouse Dependent Patient #4 information: Self Spouse Dependent Patient #5 information: Self Spouse Dependent Patient #6 information: Self Spouse Dependent Refill Orders Please print Refills can be faxed to or mailed to the address listed on page 1. Patient Name (Last, First, MI) Birth Date Prescription Number Drug Name To quickly order your refills online, go to serve-you-rx.com and click on EzRefillRx or call. Page 2 RX0016(0715)

5 Prescription Transfer Form If you currently use a mail service or local pharmacy to fill your prescriptions, you can easily transfer them to the Serve You DirectRx SM Mail Service Pharmacy by completing this form. An order will be placed for all prescriptions marked Fill on page 2. Questions can be directed to Member Services at. Mail or FAx completed form to: Serve You DirectRx Pharmacy P.O. Box Milwaukee, WI FAX Instructions: Complete page 1 and the Prescription Transfer Information on page 2. Mail or fax both pages of this completed transfer form along with payment, if applicable. For additional forms, visit serve-you-rx.com. Please print Cardholder information Establish an account* (see NOTE) Employer/Health Plan Name: Member ID #: Group #: Last Name: First Name: MI: Permanent Address: City: State: Zip: Delivery Address: City: State: Zip: (If different than the permanent address) For this order only Primary Phone #: ( ) - Secondary Phone #: ( ) - Address: Method of payment Check or Money Order: (Payable to: Serve You) Total Amount Enclosed: $ To authorize payment by credit card, please provide following information: Use Credit Card On File: Last four digits of card on file: Credit Card: MasterCard VISA American Express Discover Name as it Appears on Credit Card: Billing ZIP Code: Credit Card #: Expiration Date (month/year): / Cardholder Signature: Today s Date (month/day/year): / / I authorize Serve You to maintain my credit card on file as payment method for any future charges. I understand that all prescription orders requested by me or new prescriptions provided to Serve You by my physician will automatically be processed and shipped using this card for payment. Certification and Authorization: I certify that the information on this form is correct and further understand that any benefits are subject to my eligibility for and participation in the medical plan. I certify that I or my dependents for whom prescriptions are enclosed do not have primary prescription drug coverage under any other medical plan. NOTE: All communications, including mailed prescriptions, will be directed to the cardholder. A covered dependent who wishes to receive communications directly should include a request in writing with any prescription order. *For each account, all prescriptions ordered are sent in separate packages. Signature: Today s Date (month/day/year): / / Page 1

6 Prescription Transfer Information Please print Patient #1 information: Self Spouse Dependent Last Name: First Name: MI: Date of Birth: / / Address: Patient #2 information: Self Spouse Dependent Last Name: First Name: MI: Date of Birth: / / Address: Patient #3 information: Self Spouse Dependent Last Name: First Name: MI: Date of Birth: / / Address: Page 2 RX0023(0715)

7 Allergy, Health Conditions & Medication Questionnaire MEMBER SERVICES: MAIL OR FAX COMPLETED FORM TO: Serve You DirectRx Pharmacy P.O. Box Milwaukee, WI FAX For additional questionnaires, visit serve-you-rx.com. This information is used by Serve You DirectRx SM Mail Service Pharmacy to determine possible drug allergies and disease interactions when filling your mail service prescriptions. It is important that the information be as complete as possible as it is used by a pharmacist to help protect you against potential drug interactions and side effects. Your privacy is important to us. Serve You takes the utmost security in protecting your health information. We comply with all federal privacy regulations. Please print PATIENT INFORMATION Member ID #: Group #: Patient Last Name: Patient First Name: MI: Date of Birth: / / Primary Phone #: ( ) - Providing your address and phone number authorizes us to contact you about your account or our services. address will be used to send order tracking and shipping confirmation information. Secondary Phone #: ( ) - DRUG ALLERGIES: PLEASE SELECT ALL THAT APPLY No Known Allergies Codeine Iodine Penicillin Other: Aspirin Erythromycin Peanuts Sulfa Drugs HEALTH CONDITIONS: PLEASE SELECT ALL THAT APPLY Acid Reflux Diabetes High Blood Pressure Prostate Issues Arthritis Epilepsy High Cholesterol Thyroid Low / High Asthma Glaucoma Migraine Ulcer Depression Heart Problem Osteoporosis Other: NON-PRESCRIPTION MEDICATIONS: PLEASE SELECT ALL YOU CURRENTLY TAKE ON A REGULAR BASIS Advil /ibuprofen Aleve /naproxen sodium Bayer /aspirin Tylenol /acetaminophen Supplements/herbal medications Other: RX0017(0715

8 Allergy, Health Conditions & Medication Questionnaire MemBer SErvices: Mail or FAX completed form to: Serve You DirectRx Pharmacy P.O. Box Milwaukee, WI Fax For additional questionnaires, visit serve-you-rx.com. This information is used by Serve You DirectRx SM Mail Service Pharmacy to determine possible drug allergies and disease interactions when filling your mail service prescriptions. It is important that the information be as complete as possible as it is used by a pharmacist to help protect you against potential drug interactions and side effects. Your privacy is important to us. Serve You takes the utmost security in protecting your health information. We comply with all federal privacy regulations. Please print Patient Information Member ID #: Group #: Patient Last Name: Patient First Name: MI: Date of Birth: / / Primary Phone #: ( ) - Secondary Phone #: ( ) - Providing your address and phone number authorizes us to contact you about your account or our services. address will be used to send order tracking and shipping confirmation information. Drug Allergies: Please select all that apply No Known Allergies Codeine Iodine Penicillin Other: Aspirin Erythromycin Peanuts Sulfa Drugs Health Conditions: Please select all that apply Acid Reflux Diabetes High Blood Pressure Prostate Issues Arthritis Epilepsy High Cholesterol Thyroid Low / High Asthma Glaucoma Migraine Ulcer Depression Heart Problem Osteoporosis Other: Non-Prescription Medications: Please select all you currently take on a regular basis Advil /ibuprofen Aleve /naproxen sodium Bayer /aspirin Tylenol /acetaminophen Supplements/herbal medications Other: RX0017(0715)

9 Your Rights Regarding Your Health Information You have the following rights regarding the health information we maintain about you: Right to Request Restrictions: You have the right to request restrictions on how we use and disclose your health information for treatment, payment or healthcare operations. In most circumstances, we are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing and submit it to the Privacy Officer at the address in this notice. We are required to agree to a request that we restrict a disclosure made to a health plan for payment or healthcare operations purposes that is not otherwise required by law, if you, or someone other than the health plan on your behalf, paid for the service or item in question out-of-pocket in full. Right to Request Confidential Communications: You have the right to request that we communicate with you in a certain manner or at a certain location regarding the services you receive from us. For example, you may ask that we only contact you at work or only by mail. To request confidential communications, you must make your request in writing and submit it the Privacy Officer at the address in this notice. We will not ask you the reason for your request. We will attempt to accommodate all reasonable requests. Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. To inspect and copy your health information, you must make your request in writing by filling out the appropriate form provided by us and submitting it to the Privacy Officer at the address in this notice. You may request access to your medical information in a certain electronic form and format if readily producible or, if not readily producible, in a mutually agreeable electronic form and format. Further, you may request in writing that we transmit a copy of your health information to any person or entity you designate. Your written, signed request must clearly identify such designated person or entity and where you would like us to send the copy. If you request a copy of your health information, we may charge a cost-based fee for the labor, supplies and postage required to meet your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed by a licensed healthcare professional chosen by us. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. Right to Amend: If you feel that your health information is incorrect or incomplete, you may request that we amend your information. You have the right to request an amendment for as long as the information is kept by or for us. To request an amendment, you must make your request in writing by filling out the appropriate form provided by us and submitting it to the Privacy Officer at the address below. We may deny your request for an amendment. If this occurs, you will be notified of the reason for the denial and given the opportunity to file a written statement of disagreement with us that will become part of your medical record. Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures we make of your health information. Please note that certain disclosures need not be included in the accounting we provide to you. To request an accounting of disclosures, you must make your request in writing by filling out the appropriate form provided by us and submitting it to the Privacy Officer at the address in this notice. Your request must state a time period which may not be longer than six years and which may not include dates before April 14, The first accounting you request within a 12-month period will be free. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you of the costs involved and give you an opportunity to withdraw or modify your request before any costs have been incurred. Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time, even if you previously agreed to receive this Notice electronically. To obtain a paper copy of this Notice, please contact the Privacy Officer at the address in this notice. You may also obtain a paper copy of this Notice at our website, serve-you-rx.com. Changes to this Notice We reserve the right to change the terms of this Notice at any time. We reserve the right to make the new Notice provisions effective for all health information we currently maintain, as well as any health information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise our Notice. Each version of the Notice will have an effective date listed on the first page. Updates to this Notice are also available at our website, serve-you-rx.com. Complaints If you have any questions about this Notice or would like to file a complaint about our privacy practices, please direct your inquiries to the Privacy Officer at the address in this notice. You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be retaliated against or penalized for filing a complaint. Questions If you have questions about this Notice, please contact the Privacy Officer at the address in this notice. Privacy Officer Serve You Custom Prescription Management West Innovation Drive, Suite 600, Milwaukee, WI Phone: ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Serve You is committed to protecting your privacy and ensuring that your health information is used and disclosed appropriately. This Notice of Privacy Practices summarizes the ways we may use or disclose your health information and outlines your rights with regard to your health information. Please sign the form below to acknowledge that you have received our Notice of Privacy Practices. I acknowledge that I have been given the opportunity to receive a copy of the Notice of Privacy Practices of Serve You no later than the date I first obtained services from Serve You, or if my first date of service was an emergency treatment situation, as soon as was reasonably practicable after the emergency treatment situation. I understand that if I have any questions regarding this Notice I may contact: Privacy Officer Serve You Custom Prescription Management West Innovation Drive, Suite 600, Milwaukee, WI Phone: (Printed Name) (Signature) (Name and Signature of Personal Representative, if applicable) (Legal Authority of Personal Representative, if applicable) / / (Date Signed) Please return this signed Acknowledgment form: VIA U.S. MAIL: Privacy Officer Serve You Custom Prescription Management West Innovation Drive, Suite 600, Milwaukee, WI VIA FAX: Serve You DirectRx Mail Service and Specialty Pharmacies Fax: Serve You Custom Prescription Management CS0004(0715) NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013 This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

10 About Us In this Notice, we use terms like we, us or our to refer to Serve You DirectRx SM Mail Service and Specialty Pharmacies. ( Serve You ), its pharmacists, employees, staff and other personnel. Serve You follows the terms of this Notice and may share health information for treatment, payment, or healthcare operations purposes and for other purposes as described in this Notice. Purpose of this Notice This Notice describes how we may use and disclose your health information to carry out treatment, payment, or healthcare operations and for other purposes that are permitted or required by law. This Notice also outlines our legal duties for protecting the privacy of your health information and explains your rights to have your health information protected. We will create a record of the services we provide you, and this record will include your health information. We need to maintain this information to ensure that you receive quality care and to meet certain legal requirements related to providing your care. We understand that your health information is personal, and we are committed to protecting your privacy and ensuring that your health information is not used inappropriately. Our Responsibilities We are required by law to maintain the privacy of your health information and to provide you notice of our legal duties and privacy practices with respect to your health information. We are also required to notify you of a breach of your unsecured health information. We will abide by the terms of this Notice. How We May Use or Disclose Your Health Information The following categories describe examples of the way we use and disclose health information without your written authorization: For Treatment: We may use and disclose your health information to provide you with medical treatment or services. For example, we may contact you regarding medications, therapeutic substitution (e.g., the availability of generic products), counseling and drug utilization review (DUR), product recalls, re-fill reminders or disease state management. We may disclose your health information to another pharmacist or to your prescriber for the purpose of a consultation. For Payment: We may use and disclose your health information to others so they will pay us or reimburse you for your treatment. For example, a bill may be sent to you, your insurance company, pharmacy benefit manager or another third-party payer. The bill may contain information that identifies you, your diagnosis, and treatment or prescription medication used in the course of treatment. We may tell your health plan about a prescription medication you are going to receive to obtain prior approval or to determine whether your health plan will cover the prescription medication. For Healthcare Operations: We may use and disclose your health information in order to support our business activities. These uses and disclosures are necessary to run the mail service pharmacy and make sure our patients receive quality care. For example, we may use your health information for quality assessment activities, reviewing the competence and qualifications of the pharmacists providing treatment to you, and for other essential activities. We may also disclose your health information to third-party business associates that perform various services on our behalf, such as auditing, legal, billing and collection services. In these cases, we will enter into a written agreement with the business associate to ensure they protect the privacy of your health information. Individuals Involved in Your Care or Payment for Your Care and Notification: If you verbally agree to the use or disclosure and in certain other situations, we will make the following uses and disclosures of your health information. We may disclose to your family, friends, and anyone else you identify as involved in your medical care or who helps pay for your care health information relevant to that person s involvement in your care or paying for your care. We may also make these disclosures after your death. We may use or disclose your information to notify or assist in notifying a family member, personal representative or any other person responsible for your care regarding your general condition or death. We may also use or disclose your health information to disaster-relief organizations so that your family or other persons responsible for your care can be notified about your condition, status and location. We are also allowed to the extent permitted by applicable law to use and disclose your health information without your authorization for the following purposes: As Required by Law: We may use and disclose your health information when required to do so by federal, state or local law. Judicial and Administrative Proceedings: If you are involved in a legal proceeding, we may disclose your health information in response to a court or administrative order. We may also release your health information in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Health Oversight Activities: We may use and disclose your health information to health oversight agencies for activities authorized by law. These oversight activities are necessary for the government to monitor the healthcare system, government benefit programs, compliance with government regulatory programs and compliance with civil rights laws. Law Enforcement: We may disclose your health information, within limitations, to law enforcement officials for several different purposes: To comply with a court order, warrant, subpoena, summons or other similar process To identify or locate a suspect, fugitive, material witness or missing person About the victim of a crime, if the victim agrees or we are unable to obtain the victim s agreement About a death we suspect may have resulted from criminal conduct About criminal conduct we believe in good faith to have occurred on our premises To report a crime not occurring on our premises; the nature of a crime; the location of a crime; and the identity, description and location of the individual who committed the crime, in an emergency situation Public Health Activities: We may use and disclose your health information for public health activities, including the following: To prevent or control disease, injury, or disability To report births or deaths To report child abuse or neglect Activities related to the quality, safety or effectiveness of FDA-regulated products To notify a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition as authorized by law To notify an employer of findings concerning work-related illness or injury or general medical surveillance that the employer needs to comply with the law if you are provided notice of such disclosure Serious Threat to Health or Safety: If there is a serious threat to your health and safety or the health and safety of the public or another person, we may use and disclose your health information to someone able to help prevent the threat or as necessary for law enforcement authorities to identify or apprehend an individual. Organ/Tissue Donation: If you are an organ donor, we may use and disclose your health information to organizations that handle procurement, transplantation or banking of organs, eyes or tissues. Coroners, Medical Examiners and Funeral Directors: We may use and disclose health information to a coroner or medical examiner. This disclosure may be necessary to identify a deceased person or determine the cause of death. We may also disclose health information, as necessary, to funeral directors to assist them in performing their duties. Workers Compensation: We may disclose your health information as authorized by and to the extent necessary to comply with laws related to workers compensation or similar programs that provide benefits for work-related injuries or illness. Victims of Abuse, Neglect or Domestic Violence: We may disclose health information to the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Military and Veterans Activities: If you are a member of the Armed Forces, we may disclose your health information to military command authorities. Health information about foreign military personnel may be disclosed to foreign military authorities. National Security and Intelligence Activities: We may disclose your health information to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law. Protective Services for the President and Others: We may disclose your health information to authorized federal officials so they may provide protective services for the President and others, including foreign heads of state. Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official to assist them in providing you healthcare, protecting your health and safety or the health and safety of others, or for the safety of the correctional institution. Research: We may use and disclose your health information for certain research activities without your written authorization. For example, we might use some of your health information to decide if we have enough patients to conduct a cancer research study. For certain research activities, an Institutional Review Board (IRB) or Privacy Board may approve uses and disclosures of your health information without your authorization. Other Uses and Disclosures of Your Health Information that Require Written Authorization: Other uses and disclosures of your health information not covered by this Notice will be made only with your written authorization. Some examples include: Psychotherapy Notes: We usually do not maintain psychotherapy notes about you. If we do, we will only use and disclose them with your written authorization except in limited situations. Marketing: We may only use and disclose your health information for marketing purposes with your written authorization. This would include making treatment communications to you when we receive a financial benefit for doing so. Sale of Your Health Information: We may sell your health information only with your written authorization. If you authorize us to use or disclose your health information, you may revoke your authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your health information as specified by your revocation, except to the extent that we have taken action in reliance on your authorization.